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Should smokers be advised to cut down as well as to quit? This is the debate captured in our latest Head to Head article, just published on bmj.com. The cost effectiveness body for England and Wales, the National Institute for Health and Care Excellence (NICE), last year changed its guidance to recommend that smokers are advised to cut down rather than simply to quit smoking, as Gareth Iacobucci reported. However, to achieve this NICE also started to recommend licensed nicotine products for long term use as maintenance treatment rather than simply for smoking cessation.

In the debate, the behavioural medicine researchers Paul Aveyard and Nicola Lindson-Hawley at the University of Oxford, say that “people who are cutting down are more likely to make a future quit attempt than people who are not.” They cite physiological evidence that supports their view: “Nicotine addiction leads to neuroadaptation, and cutting down on smoking might reverse some of this, leading to less craving and withdrawal after stopping—the primary drivers of relapse.” They also note that unlicensed nicotine products are making huge gains in popularity: e-cigarettes are “the most commonly used cessation aid in England,” they say.

However, Gerard Hastings and Marisa de Andrade have a different take on the issue. They dispute e-cigarettes’ effectiveness in smoking cessation, urge caution, and suggest that NICE’s revised guidance may give these untested products implicit approval. They present long term use of nicotine products marketed by big tobacco as commercial exploitation of smokers attempting to quit.

Calling for a broader view of smoking than nicotine dependency, they say, “When the only obstacle to progress on preventing the harms of smoking is the user’s dependence, e-cigarettes offer the beguiling prospect of addicted smokers migrating painlessly to safer mechanisms of nicotine delivery.” But without evidence that e-cigarettes work, they conclude, “The tobacco multinationals have leapt enthusiastically into this market; all now have major e-cigarette interests. This is not a consumer movement but the full onslaught of corporate capital in hot pursuit of a profitable opportunity.”

Let us know what you think by voting in our poll and by posting a rapid response to the debate. We republish the most interesting and useful responses as formal letters to the editor.

In other news: a recent Personal View by an Australian district medical officer, David Berger, on his experiences of corruption in Indian medicine and healthcare is also stimulating debate. In a rapid response published today, the head of a non-profit hospital in Delhi sympathises with Berger: “Deviance has been normalized to a huge extent,” Abhishek Bhartia says, calling for a systems approach to “address myriad interrelated factors.” He also cites doctors’ low pay among other factors that need to be looked at.

E-Cigs should not be
treated or taxed in the same way that tobacco is and they do help smoking
cessation. I do however believe e-cigs should be regulated by the FDA. Just as
with tobacco the e-cig industry needs regulation due to the chemicals and other
safety issues. It is funny how the states are getting paid by the tobacco
companies to help with the rising medical cost but I have never seen or heard
of classes or offers to help someone stop smoking. If the tobacco companies are
paying the states all this money to help cessation why are the constituents not
seeing the aid in quitting smoking? If they call advertising quitting smoking
help then raising taxes and banning smoking in areas indoors and on campuses
helping they got it all backwards. When we are children it is common knowledge
the more we are told we cannot do something the more likely it is we will want
to do more of it and more often. Government is going about smoking cessation
the wrong way and I know I am a smoker of 44 years. I want to quit if the state
would buy me e-cigs for three months I believe I could stop for good. They
should start putting that money where their mouths are, suing tobacco companies
to help absorb the cost of medical and claiming to set up means to help deter
young people from starting smoking and adults to stop smoking is an outright
lie they sued to line their own pockets I have never seen any of this money.
Show me where all the money has gone certainly not on campaigning to stop or
ban smoking how is that helping the healthcare situation. Give back to the
communities and start a program where we can get counseling and a free three month
supply of an FDA approved E-cig and then we can talk!!!